Trend watch: Are more patients getting explants and returning to a more natural look?

In the ever-evolving world of plastic surgery, trendy procedures are nothing new – from Brazilian butt lifts (BBLs) to buccal fat removal, plastic surgeons tend to notice when procedures rise and fall in demand and popularity.

Some plastic surgery procedures remain relevant over time, no matter the decade – like breast implants. Breast implants have remained a staple in cosmetic surgery through the 1990s, 2000s and onward.

Or have they?

According to the 2020 ASPS Insights and Trends Report, breast augmentation procedures have decreased 9% in the past 20 years. If fewer individuals are getting breast implants, it's enough to beg the question – are we witnessing a new demand for smaller, more natural-looking breasts?

As it turns out, the topic is a bit more nuanced than that. We spoke with board-certified plastic surgeons Karen Horton, MD, MSc, FACS, FRCSC, and Josef Hadeed, MD, FACS, about breast implant removal, why people get them and addressing if we're witnessing a trend toward smaller, more natural-looking breasts.

Why people might get a breast explant

Breast implant removal, often referred to as a "breast explant," can vary widely depending on the patient's individual circumstances, including the size and type of the implants, the length of time they have been in place and the condition of the surrounding breast tissue.

Here are some of the potential reasons why people are having their implants reversed.

Aesthetic and cosmetic reasons

Some individuals may feel that their breast implants no longer align with their personal aesthetic preferences, while others may wish to embrace a more natural and authentic body image.

"I see patients looking to have their implants removed for several reasons," said Horton. "Their body has changed since they originally had surgery – usually weight gain with age or post-pregnancy, and they now feel their breasts are too big proportionally."

Horton also acknowledged the trend component: "Just like fashion, clothing and makeup, breast styles and preferences change from one decade to another."

Complications with breast implants

Some common reasons for explants include pain, capsule contracture and implant rupture.

"The mechanical issues related to implants, such as rupture, capsular contracture and implant migration, have remained, while other issues, such as ALCL associated with textured implants and breast implant illness, are newer issues," said Hadeed.

Capsular contracture is a common complication caused by a foreign body response in which the scar tissue around the implant hardens and contracts. The biofilm theory suggests bacterial contamination can contribute to capsular contracture and other issues. Asymmetry may result from implant malposition or uneven tissue distribution, while malposition occurs when the implant shifts out of place. In some cases, explants may be necessary to address these complications.

Concerns surrounding BIA-ALCL, BIA-SCC and BII

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), breast implant-associated squamous cell carcinoma (BIA-SCC) and breast implant illness (BII) have become significant concerns for women who have undergone breast augmentation.

However, Horton noted that vague symptoms such as fatigue, weight gain, brain fog and worries about BII are rare. This sentiment is echoed by Hadeed as well.

"There are many reasons why women wish to have their breast implants removed," said Hadeed. "In some instances, they just don't wish to be that large-chested anymore. In other cases, they may have experienced either discomfort from implant migration or rupture of the implant and don't wish to have them replaced. In recent years, the term 'breast implant illness' has come up, which is a constellation of symptoms, and some women have asked to have their implants removed."

Breast implants are approved by the U.S. Food and Drug Administration (FDA) for breast augmentation and breast reconstruction. And while the majority of women with breast implants experience no serious complications, there are risks associated with breast implants, and some women opt for an explant.

One study, for instance, revealed that the search volume for breast implant removal correlated with various factors, including media coverage of breast implant-related illnesses and regulatory actions taken by the FDA. For example, the FDA's announcement of a voluntary recall of specific breast implants in 2019 was associated with a surge in search volume.

Additionally, there has been increased awareness about BIA-ALCL, a rare but potentially life-threatening cancer that can develop in the scar tissue surrounding the implant.

"I personally have not seen BIA-ALCL – I don't use textured implants – nor BIA-SCC," said Horton. "But if a change in the breast is occurring in the presence of a breast implant, patients should always be seen and examined by a board-certified plastic surgeon to rule out any common or rare conditions such as those mentioned."

Breast explants: A future of smaller, more natural chests?

While the above lists reasons why more people are getting explants, it's too early to tell if we're seeing a trend toward natural breasts, but the preferred size may be decreasing due to the reasons above.

"I don't believe [breast implant reversal] is related to an aesthetic trend," said Hadeed. "In our practice, some women with larger implants don't wish to remain as large but still desire implants, and in those cases, we might replace their current implants with a smaller size."

Whether it's an implant or an explant, it is important to understand the causes and potential risks before undergoing any breast procedure to make an informed decision.

To find a qualified plastic surgeon for any cosmetic or reconstructive procedure, consult a member of the American Society of Plastic Surgeons. All ASPS members are board certified by the American Board of Plastic Surgery, have completed an accredited plastic surgery training program, practice in accredited facilities and follow strict standards of safety and ethics. Find an ASPS member in your area.